Department of Anesthesiology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA.
Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Health, Palo Alto, CA, USA.
Paediatr Anaesth. 2020 May;30(5):564-570. doi: 10.1111/pan.13839. Epub 2020 Feb 24.
Patients supported with a ventricular assist device are predisposed to severe bleeding at the time of orthotopic heart transplant due to several risk factors including anticoagulation with vitamin K antagonists. Kcentra, a four-factor prothrombin complex concentrate, has been approved by the FDA for warfarin reversal in adults prior to urgent surgery. There is a lack of published data on the preoperative use of four-factor prothrombin complex concentrates in pediatric patients undergoing cardiacsurgery.
This is a single-center retrospective analysis of pediatric patients with a continuous-flow ventricular assist device who underwent heart transplant, comparing patients who received Kcentra for anticoagulation reversal with a historical patient cohort who did not. Consecutive patients from January 2013 to December 2017 were analyzed. The primary outcome was volume of blood product transfusion prior to cardiopulmonary bypass initiation. Secondary outcomes include blood product transfusion after cardiopulmonary bypass intraoperatively and up to 24 hours postoperatively, chest tube output within 24 hours of surgery, time to extubation, incidence of thromboembolism, and post-transplant length ofstay.
From 2013 to 2017, 31 patients with continuous-flow ventricular assist devices underwent heart transplant, with 27 patients included in the analysis. Fifteen patients received Kcentra compared with 12 patients who received fresh-frozen plasma for anticoagulation reversal. Compared with the control group, patients who received Kcentra had less packed red blood cells, fresh-frozen plasma, and platelets transfused prior to cardiopulmonary bypass initiation. The Kcentra group also received less packed red blood cells on bypass and less packed red blood cells after cardiopulmonary bypass termination. There were no differences in chest tube output, time to extubation, intensive care unit length of stay, or overall hospital length of stay. Neither group had thromboembolic complications detected during the first seven postoperative days.
This small retrospective study indicates that preoperative warfarin reversal with Kcentra reduces blood product exposure in pediatric patients with ventricular assist devices undergoing heart transplant.
由于多种风险因素的存在，包括使用维生素 K 拮抗剂进行抗凝治疗，接受心室辅助装置支持的患者在进行原位心脏移植时容易发生严重出血。Kcentra 是一种四因子凝血酶原复合物浓缩物，已被 FDA 批准用于在紧急手术前逆转华法林在成人中的作用。在接受心脏手术的儿科患者中，术前使用四因子凝血酶原复合物浓缩物的相关数据尚未发表。
这是一项对接受心脏移植的连续血流心室辅助装置患儿的单中心回顾性分析，比较了接受 Kcentra 逆转抗凝治疗的患者与未接受 Kcentra 治疗的历史患者队列。分析了 2013 年 1 月至 2017 年 12 月连续患者。主要结局是体外循环开始前输血产品的量。次要结局包括体外循环后和术后 24 小时内的输血产品、术后 24 小时内的胸管输出量、拔管时间、血栓栓塞发生率和移植后住院时间。
2013 年至 2017 年，31 例连续血流心室辅助装置患者接受心脏移植，其中 27 例患者入组分析。15 例患者接受了 Kcentra，12 例患者接受了新鲜冷冻血浆进行抗凝逆转。与对照组相比，接受 Kcentra 的患者在体外循环前输血的红细胞、新鲜冷冻血浆和血小板更少。Kcentra 组在体外循环期间和体外循环终止后也接受了更少的红细胞。两组的胸管输出量、拔管时间、重症监护病房住院时间或总住院时间均无差异。两组在术后 7 天内均未发现血栓栓塞并发症。
这项小型回顾性研究表明，Kcentra 用于术前华法林逆转可减少接受心脏移植的心室辅助装置患儿的血液制品暴露。
